Related Resources • Links to CABG surgery • Links to angioplasty

By DrRich

Dateline: October 21, 2002

The recent repeal, in several states, of regulations governing bypass surgery and angioplasty may be having an adverse effect on patients.

In the October 16 issue of the Journal of the American Medical Association, researchers report that the death rate among patients who have coronary artery bypass grafting (CABG) is significantly higher in states that have repealed their certificate-of-need (CON) regulations, as compared to states that have not.

The CON regulations were developed under federal guidelines in 1974 as a means of controlling costs and maintaining quality health care.  Essentially, the CON process requires a hospital to apply for special certification from the state before embarking on certain high-cost and high-tech procedures, such as bypass surgery and angioplasty.  To a large extent, the CON process tended to keep such procedures in the larger, high-volume hospitals. 

In the 1980s, however, many states began repealing their CON requirements, largely in the name of deregulation and open competition.  In these states, any hospital that wanted to could begin open heart surgery and other high-tech cardiac programs.  Because these medical procedures tend to be very well-reimbursed, many smaller hospitals did just that.

In order to measure whether the repeal of CON requirements had any effect on medical outcomes, the authors of the recent JAMA article examined the risk of death in over 900,000 Medicare patients who received CABG surgery in over 1000 U.S. hospitals between 1994 and 1999. They found that, among the 18 states that have repealed their CON requirements for bypass surgery programs, the mortality rate was 20% higher than for states that have maintained CON requirements.

They also found that in states without CON requirements, CABG patients were much more likely to have had a failed angioplasty procedure the same day as the CABG procedure. (In other words, their CABG surgery became necessary on an emergency basis because an angioplasty procedure went bad.  Mortality rates for emergency CABG surgery have been shown to be significantly higher than for elective CABG surgery.) 

Finally, they found that the number of CABG operations performed per hospital was 84% lower in states without, as compared to states with, CON requirements.  (The number of CABG operations performed in a hospital has been shown to correlate well with medical outcomes - high-volume hospitals tend to have better results.)

See below for a list of states that have repealed their CON requirements.

What this means

Repeal of the CON requirements have allowed smaller hospitals to engage in procedures that they are relatively ill-equipped to perform.  Specifically, the outcome of CABG surgery depends on far more than the skills of the surgeon.  Post-op care of the CABG patient can be quite difficult and complex, and unless a hospital is fully staffed and skilled to run a state-of-the art surgical intensive care unit, and has all the appropriate specialists available 24 hours per day to deal with unexpected complications, one ought not expect the outcomes to be equivalent to a hospital that is geared up to do so.  The results of this study should not surprise anybody.  While there are exceptions, in general small hospitals simply should not be expected to perform as well as the larger hospitals in conducting complex, high-tech, high-intensity clinical programs.

What to be aware of if you need CABG or angioplasty

Whether a state maintains or repeals its CON requirements is often a matter of which lobbying groups predominate in that state, and patients facing cardiac procedures should not expect to have much of a voice in this political decision.  You can't pick what your state legislature will do, but you can pick where you are going to receive your care, no matter which state you live in. And in picking your venue of care, you need to strongly consider the results of this study.

The take-home message from this study is to try to choose a high-volume hospital if you're going to have angioplasty or CABG surgery performed.  It might be more convenient to have the work done your smaller local hospital - it's familiar to you, and it's close to home and family (and, by the way, to your favorite funeral home).  But you pay for this convenience, on average, with a 20% higher likelihood of dying with your CABG procedure.

This choice is probably as important as picking your doctor.  Picking the right doctor is still important, but the environment in which that doctor works is also critical.  The same surgeon might have great results in Hospital A, and only so-so results in Hospital B. 

While the JAMA study does not directly address CON requirements for angioplasty, it appears that most states that repeal the CON for one also repeal the CON for the other.  And while angioplasty, when all goes well, does not require the army of support personnel required by CABG, angioplasty does not always go well.  So ask yourself: if you need emergency surgery after angioplasty, do you want the surgery done in that hospital?

Which states have repealed CON requirements for CABG surgery?

The following 18 states had no CON requirements for CABG surgery from 1994 through 1999, the years of this study:

Arizona, Akansas, California, Colorado, Idaho, Indiana, Kansas, Louisiana, Minnesota, Montana, New Mexico, Oklahoma, Oregon, South Dakota, Texas, Utah, Wisconsin and Wyoming.

The following 6 states have repealed their CON requirements since 1994 (and were not included in the "no CON" group in this study):

Delaware, Nebraska, Nevada, North Dakota, Ohio, Pennsylvania

 Caveat emptor.